Peak oxygen consumption and long-term all-cause mortality in nonsmall cell lung cancer

Cardiopulmonary exercise testing prior to myeloablative allo-SCT: a feasibility study

The feasibility of symptom-limited cardiopulmonary exercise testing (CPET) prior to allo-SCT was assessed in addition to the prognostic value of CPET-derived measures. CPET was performed prospectively on 21 patients with hematologic malignancies, with assessments of peak (for example, peak oxygen consumption, VO2peak) and submaximal (for example, ventilatory threshold (VT)) measures of cardiopulmonary function. No serious adverse events were observed during CPET procedures, with 95% of patients achieving criteria for a peak test. Mean VO2peak was 24.7±6.4 mL kg(-1 )min(-1) (range: 10.9-35.5), equivalent to 29%±17% below that of age-matched healthy controls. All patients proceeded with the conditioning regimen followed by allo-SCT. Median follow-up was 25 months. During this period, 11 (52.4%) patients died (n=6, relapsed disease; n=5, non-relapse mortality (NRM)); 9 patients (43%) developed pulmonary toxicity. In univariate analyses, both peak and submaximal markers of cardiopulmonary function were predictors of OS, pulmonary toxicity and NRM. For OS, the HR for VO2peak and VT were 0.89 (95% CI, 0.8-0.99, P=0.04) and 0.84 (95% CI, 0.71-0.98, P=0.03), respectively. In conclusion, CPET is safe and feasible prior to allo-SCT. Patients have marked impairments in cardiopulmonary function prior to allo-SCT. CPET-derived metrics may complement conventional measures to improve risk stratification.

Running away from side effects: physical exercise as a complementary intervention for breast cancer patients

The number of breast cancer survivors increases every year, thanks to the development of new treatments and screening techniques. However, patients present with numerous side effects that may affect their quality of life. Exercise has been demonstrated to reduce some of these side effects, but in spite of this, few breast cancer patients know and follow the exercise recommendations needed to remain healthy. In this review, we describe the different breast cancer treatments and the related side effects and implications of exercise in relation to these. We propose that exercise could be an integrative complementary intervention to improve physiological, physical and psychological factors that affect survival and quality of life of these patients. For that reason, the main objective of this review is to provide a general overview of exercise benefits in breast cancer patients and recommendations of how to design exercise interventions in patients with different side effects.

Clinical implications of body composition assessment by computed tomography in metastatic renal cell carcinoma

According to computed tomography image analysis, skeletal muscle (SM) and adipose tissue areas vary widely in patients with the same body mass index or the same body surface area. Body composition variables such as SM mass, SM density and subcutaneous and visceral adipose tissue have shown value as potential independent predictive factors for survival in cancer patients, although data for patients with renal cell carcinoma (RCC) undergoing targeted therapy remain relatively scarce. Confirmation of their prognostic value is required before they can be considered useful adjuncts to conventional predictive models of survival in RCC patients. In addition, variability in SM mass might affect drug toxicity, with patients with a low rather than high SM mass being at a higher risk of toxicity. A dose tailored to the individual patient's SM mass might lower toxicity in RCC patients, enable completion of the treatment plan and thus impact favorably on treatment effectiveness.

Utility of 3-dimensional echocardiography, global longitudinal strain, and exercise stress echocardiography to detect cardiac dysfunction in breast cancer patients treated with doxorubicin-containing adjuvant therapy

Conventional resting left ventricular ejection fraction (LVEF) assessments have limitations for detecting doxorubicin (DOX)-related cardiac dysfunction. Novel resting echocardiographic parameters, including 3-dimensional echocardiography (3DE) and global longitudinal strain (GLS), have potential for early identification of chemotherapy-related myocardial injury. Exercise "stress" is an established method to uncover impairments in cardiac function but has received limited attention in the adult oncology setting. We evaluated the utility of an integrated approach using 3DE, GLS, and exercise stress echocardiography for detecting subclinical cardiac dysfunction in early breast cancer patients treated with DOX-containing chemotherapy. Fifty-seven asymptomatic women with early breast cancer (mean 26 ± 22 months post-chemotherapy) and 20 sex-matched controls were studied. Resting left ventricular (LV) function was assessed by LVEF using 2-dimensional echocardiography (2DE) and 3DE and by GLS using 2-dimensional speckle-tracking echocardiography (2D-STE). After resting assessments, subjects completed cardiopulmonary exercise testing with stress 2DE. Resting LVEF was lower in patients than controls by 3DE (55 ± 4 vs. 59 ± 5 %; p = 0.005) but not 2DE (56 ± 4 vs. 58 ± 3 %; p = 0.169). 10 of 51 (20 %) patients had GLS greater than or equal to -17 %, which was below the calculated lower limit of normal (control mean 2SD); this patient subgroup had a mean 20 % impairment in GLS (-16.1 ± 0.9 vs. -20.1 ± 1.5 %; p < 0.001), despite similar LVEF by 2DE and 3DE compared to controls (p > 0.05). Cardiopulmonary function (VO2peak) was 20 % lower in patients than controls (p < 0.001). Exercise stress 2DE assessments of stroke volume (61 ± 11 vs. 69 ± 15 ml; p = 0.018) and cardiac index (2.3 ± 0.9 vs. 3.1 ± 0.8 l min(-1) m(-2) mean increase; p = 0.003) were lower in patients than controls. Post-exercise increase in cardiac index predicted VO2peak (r = 0.429, p = 0.001). Resting 3DE, GLS, and exercise stress 2DE detect subclinical cardiac dysfunction not apparent with resting 2DE in post-DOX breast cancer patients.

Neuromuscular electrical stimulation of the quadriceps in patients with non-small cell lung cancer receiving palliative chemotherapy: a randomized phase II study

BACKGROUND

A reduced exercise capacity is associated with increased morbidity and mortality in patients with advanced non-small cell lung cancer (NSCLC). Therapeutic exercise can be beneficial and neuromuscular electrical stimulation (NMES) of the quadriceps muscles may represent a practical approach. The primary aim of this study was to determine the acceptability of NMES of the quadriceps to patients with NSCLC used alongside palliative chemotherapy. Secondary aims explored aspects of safety and efficacy of NMES in this setting.

METHODS

Patients with advanced NSCLC due to receive first-line palliative chemotherapy were randomized to usual care with or without NMES. They were asked to undertake 30 minute sessions of NMES, ideally daily, but as a minimum, three times weekly. For NMES to be considered acceptable, it was predetermined that ≥80% of patients should achieve this minimum level of adherence. Qualitative interviews were held with a subset of patients to explore factors influencing adherence. Safety was assessed according to the Common Terminology Criteria for Adverse Events. Quadriceps muscle strength, thigh lean mass, and physical activity level were assessed at baseline and after three cycles of chemotherapy.

RESULTS

49 patients (28 male, median (IQR) age 69 (64-75) years) participated. Of 30 randomized to NMES, 18 were eligible for the primary endpoint, of whom 9 (50% [90% CI, 29 to 71]) met the minimum level of adherence. Adherence was enhanced by incorporating sessions into a daily routine and hindered by undesirable effects of chemotherapy. There were no serious adverse events related to NMES, nor significant differences in quadriceps muscle strength, thigh lean mass or physical activity level between groups.

CONCLUSIONS

NMES is not acceptable in this setting, nor was there a suggestion of benefit. The need remains to explore NMES in patients with cancer in other settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 42944026 www.controlled-trials.com/ISRCTN42944026.

Low physical activity levels and functional decline in individuals with lung cancer

OBJECTIVES

Physical activity has been infrequently measured objectively in non-small cell lung cancer (NSCLC). We aimed to investigate levels of physical activity, functional and patient reported outcomes at diagnosis and over six months in participants with recently diagnosed NSCLC and compare results with both physical activity guidelines and outcomes of similar-aged healthy individuals.

METHODS

This prospective observational study assessed 50 individuals from three Australian tertiary hospitals with stage I-IIIB NSCLC at diagnosis, then 10 weeks and six months later. Thirty five healthy individuals without cancer were assessed once. Outcome measures included tri-axial accelerometery (number of steps per day), six minute walk distance (6MWD), muscle strength and questionnaires including health-related quality of life (HRQoL).

RESULTS

Individuals with NSCLC were engaged in significantly less physical activity than similar-aged healthy individuals, with 60% not meeting physical activity guidelines. At diagnosis they had worse quadriceps strength, nutritional status and HRQoL. Over six months, participants with NSCLC experienced decline in self-reported physical activity, 6MWD and muscle strength, and worsening symptoms.

CONCLUSION

At diagnosis individuals with NSCLC engage in less physical activity, are weaker and more depressed than healthy individuals and their self-reported physical activity declines over six months. Future studies are required to investigate the efficacy of interventions to increase physical activity.

[Managing nutritional support in thoracic oncology]

INTRODUCTION

Cancer treatments are based on specific anticancer chemotherapy. However, there is increasing interest in general aspects of care, which are increasingly evidence based.

STATE OF THE ART

The importance of muscle mass is becoming increasingly evident. Its role is not only limited to the maintenance of physical performance and quality of life. In oncology, recent studies have shown a close link between sarcopenia (low muscle mass) and mortality as well as between sarcopenia and chemotherapy toxicity. To treat malnutrition and the lack of energy intake, nutritional support is considered, whether through the prescription of oral nutritional supplements, enteral nutrition or even parenteral nutrition. Scientific arguments are often absent and few studies have been carried out in patients with lung cancer.

PERSPECTIVES

There are many experimental arguments and a few clinical trials that support using omega 3 fatty acids to modulate inflammatory reaction and to reduce its consequences on muscular proteolysis. The benefit of regular physical activity has already been proven in chronic respiratory disease and its use in association with nutritional support must be recommended in oncologic care.

CONCLUSION

Given the increasing recognition of the role of muscle mass in cancer, the purpose of any nutritional support must be focused on increasing muscle anabolism and decreasing proteolysis.

Skeletal muscle density predicts prognosis in patients with metastatic renal cell carcinoma treated with targeted therapies

BACKGROUND

Studies have shown that skeletal muscle and adipose tissue are linked to overall survival (OS) and progression-free survival (PFS). Because targeted therapies have improved the outcome in patients with metastatic renal cell carcinoma (mRCC), new prognostic parameters are required. The objective of the current study was to analyze whether body composition parameters play a prognostic role in patients with mRCC.

METHODS

Adipose tissue, skeletal muscle, and skeletal muscle density (SMD) were assessed with computed tomography imaging by measuring cross-sectional areas of the tissues and mean muscle Hounsfield units (HU). A high level of mean HU indicates a high SMD and high quality of muscle. OS and PFS were estimated using the Kaplan-Meier method and compared with the log-rank test. The multivariable Cox proportional hazards model was adjusted for Heng risk score and treatment.

RESULTS

In the 149 patients studied, the median OS was 21.4 months and was strongly associated with SMD; the median OS in patients with low SMD was approximately one-half that of patients with high SMD (14 months vs 29 months; P = .001). After adjustment for Heng risk score and treatment, high SMD was associated with longer OS (hazards ratio, 1.85; P = .004) and longer PFS (hazards ratio, 1.81; P = .002). Adding SMD will separate the intermediate-risk and favorable-risk groups into 3 groups, with different median OS periods ranging from 8 months (95% confidence interval [95% CI], 6 months-12 months) for an intermediate-risk Heng score/low SMD to 22 months (95% CI, 14 months-27 months) for an intermediate-risk Heng score/high SMD and a favorable-risk Heng score/low SMD to 35 months (95% CI, 24 months-43 months) for a favorable-risk Heng score/high SMD.

CONCLUSIONS

High muscle density appears to be independently associated with improved outcome and could be integrated into the prognostic scores thereby enhancing the management of patients with mRCC.

Cardiopulmonary fitness in patients undergoing hematopoietic SCT: a pilot study

Hematopoietic cell transplantation (HCT) is a life-saving treatment for patients with high-risk hematological malignancies. Prognostic measures to determine fitness for HCT are needed to inform decision-making and interventions. VO(2peak) is obtained by measuring gas exchange during cycle ergometry and has not been studied as a prognostic factor in HCT. Thirty-two autologous and allogeneic HCT patients underwent VO(2peak) and 6 Minute Walk (6MW) testing before HCT, and provided weekly symptom and health-related quality of life (HRQOL) assessments before HCT and concluding at Day 100. Twenty-nine patients completed pre-HCT testing. Pre-HCT VO(2peak) was positively correlated with pre-HCT 6MW (r=0.65, P<0.001) and negatively correlated with number of chemotherapy regimens and months of chemotherapy. Patients with lower VO(2peak) reported higher symptom burden and inferior HRQOL at baseline and during early post-HCT period. Patients with pre-HCT VO(2peak) <16 mL/kg/min had higher risk of mortality post HCT (entire cohort: hazard ratio (HR) 9.1 (1.75-47.0), P=0.01; allogeneic HCT patients only: HR 6.70 (1.29-34.75), P=0.02) and more hospitalized days before Day 100 (entire cohort: median 33 vs 19, P=0.003; allogeneic HCT patients only: median 33 vs 21, P=0.004). VO(2peak) pre-HCT is feasible and might predict symptom severity, HRQOL and mortality. Additional studies are warranted.

Effects and potential mechanisms of exercise training on cancer progression: a translational perspective

Over the past decade there has been increasing research and clinical interest in the role of exercise therapy/rehabilitation as an adjunct therapy to improve symptom control and management following a cancer diagnosis. More recently, the field of 'exercise - oncology' has broadened in scope to investigate whether the benefits extend beyond symptom control to modulate cancer-specific outcomes (i.e., cancer progression and metastasis). Here we review the extant epidemiological evidence examining the association between exercise behavior, functional capacity/exercise capacity, and cancer-specific recurrence and mortality as well as all-cause mortality individuals following a cancer diagnosis. We also evaluate evidence from clinical studies investigating the effects of structured exercise on blood-based biomarkers associated with cancer progression/metastasis as well findings from preclinical investigations examining the effects and molecular mechanisms of exercise in mouse models of cancer. Current gaps in knowledge are also discussed.

Molecular mechanisms underlying skeletal muscle weakness in human cancer: reduced myosin-actin cross-bridge formation and kinetics

Many patients with cancer experience physical disability following diagnosis, although little is known about the mechanisms underlying these functional deficits. To characterize skeletal muscle adaptations to cancer in humans, we evaluated skeletal muscle structure and contractile function at the molecular, cellular, whole-muscle, and whole-body level in 11 patients with cancer (5 cachectic, 6 noncachectic) and 6 controls without disease. Patients with cancer showed a 25% reduction in knee extensor isometric torque after adjustment for muscle mass (P < 0.05), which was strongly related to diminished power output during a walking endurance test (r = 0.889; P < 0.01). At the cellular level, single fiber isometric tension was reduced in myosin heavy chain (MHC) IIA fibers (P = 0.05) in patients with cancer, which was explained by a reduction (P < 0.05) in the number of strongly bound cross-bridges. In MHC I fibers, myosin-actin cross-bridge kinetics were reduced in patients, as evidenced by an increase in myosin attachment time (P < 0.01); and reductions in another kinetic parameter, myosin rate of force production, predicted reduced knee extensor isometric torque (r = 0.689; P < 0.05). Patients with cancer also exhibited reduced mitochondrial density (-50%; P < 0.001), which was related to increased myosin attachment time in MHC I fibers (r = -0.754; P < 0.01). Finally, no group differences in myofilament protein content or ultrastructure were noted that explained the observed functional alterations. Collectively, our results suggest reductions in myofilament protein function as a potential molecular mechanism contributing to muscle weakness and physical disability in human cancer.

Exercise-oncology research: past, present, and future

Significant progress has been made in the field of exercise-oncology research over the past two decades. As the field continues to forge ahead, it is time to reflect on past accomplishments in order to inform and define the critical unanswered questions postulated to have the largest impact on the field and on clinical care. Against this background, we overview the extant literature base together with ongoing/planned studies examining the role of exercise therapy following a cancer diagnosis with a view towards identifying major gaps in the knowledge.

METHOD

We adapted the Physical Exercise Across the Cancer Experience (PEACE) organizational framework to systematically overview published as well as ongoing studies of exercise therapy across the cancer survivorship continuum [i.e. 1) pretreatment; 2) during treatment; and 3) post-treatment]. To overview ongoing studies, we performed a systematic review of all exercise trials in adult cancer patients registered in Clinical Trials.Gov and the International Standard Randomized Controlled Trial Number Register.

RESULTS

Data from published studies provides relatively strong evidence that exercise therapy is a well-tolerated and safe adjunct therapy that can mitigate several common treatment-related side effects among cancer patients across the PEACE framework. In addition, observational studies suggest that higher levels of exercise may be associated with improved prognosis in patients with solid tumors. Regarding ongoing studies, a total of 82 independent clinical studies were identified. Consistent with prior work, most ongoing studies are being conducted either during or following adjuvant therapy in women with breast cancer with exercise interventions following standard exercise prescription guidelines. Across all studies, there were a total of approximately 51 different primary endpoints; in two-thirds of studies, quality of life, fatigue, or physical functioning was the primary endpoint.

CONCLUSION

There have been significant leaps in knowledge regarding the role and efficacy of exercise therapy in cancer survivors over the past 25 years. On the platform of this evidence base, it is now time to launch the next generation of research to ensure continued progress in this emergent field. This work will continue to contribute to the ultimate goal of improving both the quantity and quality of life of persons diagnosed with cancer.

Insights into the reluctance of patients with late-stage cancer to adopt exercise as a means to reduce their symptoms and improve their function

CONTEXT

Exercise reduces cancer-related disablement and adverse symptoms, yet patients' attitudes toward exercise remain largely unexamined.

OBJECTIVES

This qualitative study sought to characterize the beliefs of patients with late-stage disease regarding exercise, its relationship to their symptoms, and their clinicians' roles in providing related counseling.

METHODS

Semistructured interviews with 20 adults (half male and half aged 65 years or older) with Stage IIIB or IV nonsmall cell lung cancer were qualitatively analyzed. Participants were questioned about their levels of activity, the influence of their symptoms on their activities, perceived barriers and facilitators for exercise, and exercise-related instructions received from their professional caregivers.

RESULTS

Participants overwhelmingly cited usual daily activities as their source of "exercise." Symptoms, particularly treatment-related, discouraged participation, with fear of harm being a significant concern only among younger women. Exercise was recognized as important for physical and mental well-being but seldom as a means to mitigate symptoms. Weather, recalled levels of premorbid fitness, and exercise participation modulated current exercise behaviors. Although respondents preferred to receive guidance from their oncologist, none reported receiving more than general encouragement to "stay active." A lack of direction was typically accepted as a sanction of their current activity levels. Participants appeared less receptive to guidance from ancillary health professionals.

CONCLUSION

Effective use of exercise and activity modification to ameliorate cancer-related symptoms appears to require a linkage to a patient's usual and past activities, proactive negotiation of potential barriers, education regarding symptoms and exercise, and the positive support of their oncologist.

Cardiopulmonary function and age-related decline across the breast cancer survivorship continuum

PURPOSE

To evaluate cardiopulmonary function (as measured by peak oxygen consumption [VO(2peak)]) across the breast cancer continuum and its prognostic significance in women with metastatic disease.

PATIENTS AND METHODS

Patients with breast cancer representing four cross-sectional cohorts--that is, (1) before, (2) during, and (3) after adjuvant therapy for nonmetastatic disease, and (4) during therapy in metastatic disease--were studied. A cardiopulmonary exercise test (CPET) with expired gas analysis was used to assess VO(2peak). A Cox proportional hazards model was used to estimate the risk of death according to VO(2peak) category (< 15.4 v ≥ 15.4 mL · kg(-1) · min(-1)) with adjustment for clinical factors.

RESULTS

A total of 248 women (age, 55 ± 8 years) completed a CPET. Mean VO(2peak) was 17.8 ± a standard deviation of 4.3 mL · kg(-1) · min(-1), the equivalent of 27% ± 17% below age-matched healthy sedentary women. For the entire cohort, 32% had a VO(2peak) less than 15.4 mL · kg(-1) · min(-1)--the VO(2peak) required for functional independence. VO(2peak) was significantly different across breast cancer cohorts for relative (mL · kg(-1) · min(-1)) and absolute (L · min(-1)) VO(2peak) (P = .017 and P < .001, respectively); VO(2peak) was lowest in women with metastatic disease. In patients with metastatic disease (n = 52), compared with patients achieving a VO(2peak) ≤ 1.09 L · min(-1), the adjusted hazard ratio for death was 0.32 (95% CI, 0.16 to 0.67, P = .002) for a VO(2peak) more than 1.09 L · min(-1).

CONCLUSION

Patients with breast cancer have marked impairment in VO(2peak) across the entire survivorship continuum. VO(2peak) may be an independent predictor of survival in metastatic disease.

Effects of exercise training on exercise capacity in patients with non-small cell lung cancer receiving targeted therapy

PURPOSE

Peak oxygen consumption (VO(2peak)) is an important predictive factor for long-term prognosis in patients with non-small cell lung cancer (NSCLC). The purpose of this study was to investigate whether 8 weeks of exercise training improves exercise capacity, as assessed by VO(2peak), and other related factors in patients with NSCLC receiving targeted therapy.

METHODS

A total of 24 participants with adenocarcinoma were randomly assigned to either the control group (n = 11) or the exercise group (n = 13). Subjects in the exercise group participated in individualized, high-intensity aerobic interval training of exercise. The outcome measures assessed at baseline and after 8 weeks were as follows: VO(2peak) and the percentage of predicted VO(2peak) (%predVO(2peak)), muscle strength and endurance of the right quadriceps, muscle oxygenation during exercise, insulin resistance as calculated by the homeostasis model, high-sensitivity C-reactive protein, and quality of life (QoL) questionnaire inventory.

RESULTS

No exercise-related adverse events were reported. After exercise training, VO(2peak) and %predVO(2peak) increased by 1.6 mL kg(-1) min(-1) and 5.3% (p < 0.005), respectively; these changes were associated with improvements in circulatory, respiratory, and muscular functions at peak exercise (all p = 0.001). The exercise group also had less dyspnea (p = 0.01) and favorably lower fatigue (p = 0.05) than baseline.

CONCLUSIONS

Patients with NSCLC receiving targeted therapy have quite a low exercise capacity, even with a relatively high QoL. Exercise training appears to improve exercise capacity and alleviate some cancer-related symptoms.

Exercise rehabilitation in patients with cancer

Emerging evidence indicates that patients with cancer have considerable impairments in cardiorespiratory fitness, which is likely to be a result of the direct toxic effects of anticancer therapy as well as the indirect consequences secondary to therapy (for example, deconditioning). This reduced cardiorespiratory fitness is associated with heightened symptoms, functional dependence, and possibly with an increased risk of cardiovascular morbidity and mortality. Current understanding of the complex interaction between the effects of the tumour and cancer-associated therapies on the organ components that govern cardiorespiratory fitness, and the effects of exercise training on these parameters is limited; further research will be critical for further progress of exercise-based rehabilitation in the oncology setting. We assess the current evidence regarding the level, mechanisms, and clinical importance of diminished cardiorespiratory fitness in patients with cancer. The efficacy and adaptations to exercise training to prevent and/or mitigate dysfunction in conjunction with exercise prescription considerations for clinical use are also discussed.

Prognostic significance of functional capacity and exercise behavior in patients with metastatic non-small cell lung cancer

BACKGROUND

To investigate the prognostic importance of functional capacity and exercise behavior in patients with metastatic non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Using a prospective design, 118 consecutive participants with histologically confirmed metastatic (inoperable) NSCLC and Eastern Cooperative Oncology group (ECOG) 0-3 completed a six-minute walk test to assess functional capacity and questionnaire that assessed self-reported exercise behavior. Cox proportional models were used to estimate the risk of all-cause mortality according to six-minute walk distance (6MWD) (<358.5m, 358.5-450 m, ≥450 m) and exercise behavior (MET-hrswk(-1)) categories with adjustment for important covariates.

RESULTS

Median follow-up was 26.6 months; 77 deaths were reported during this period. Functional capacity was an independent predictor of survival (P(trend)=0.003) and added incremental prognostic value beyond that provided by PS plus other traditional markers of prognosis (P(trend)=0.025). Compared with patients achieving a 6MWD <358.5m, the adjusted hazard ratio (HR) for all-cause mortality was 0.61 (95% CI, 0.34-1.07) for a 6MWD of 358.5-450 m, and 0.48 (95% CI, 0.24-0.93) for a 6MWD >450 m. In unadjusted analysis, there was a borderline significant effect of exercise behavior on survival (p=0.052). Median survival was 12.89 months (95% CI, 9.11-21.05 months) for those reporting <9MET-hrswk(-1) compared with 25.63 months (95% CI, 11.28 to ∞ months) for those reporting ≥9MET-hrswk(-1).

CONCLUSIONS

Functional capacity is a strong independent predictor of survival in advanced NSCLC that adds to the prediction of survival beyond traditional risk factors. This parameter may improve risk stratification and prognostication in NSCLC.

Pre-cachexia in patients with stages I-III non-small cell lung cancer: systemic inflammation and functional impairment without activation of skeletal muscle ubiquitin proteasome system

Cachexia is a prevalent phenomenon of non-small cell lung cancer (NSCLC) which is responsible for increased mortality and deterioration of physical performance. Preclinical research indicates that systemic inflammation induces cachexia-related muscle wasting through muscular Nuclear Factor-kappa B (NF-κB) signaling and subsequent ubiquitin proteasome system (UPS)-mediated proteolysis. As these pathways could be a target for early intervention strategies, it needs to be elucidated whether increased activation of these pathways is already present in early stage NSCLC cachexia. The aim of the present study was therefore to assess muscular NF-κB and UPS activation in patients with NSCLC pre-cachexia. Sixteen patients with newly diagnosed stages I-III NSCLC having <10% weight loss and ten healthy controls were studied. Body composition, systemic inflammation and exercise capacity were assessed in all subjects and NF-κB and UPS activity in vastus lateralis muscle biopsies in a subset. Patients showed increased plasma levels of C-reactive protein (CRP) (P<0.001), soluble Tumor Necrosis Factor receptor 1 (sTNF-R1) (P<0.05), fibrinogen (P<0.001) and decreased levels of albumin (P<0.001). No changes in fat free body mass or skeletal muscle NF-κB and UPS activity were observed, while peak oxygen consumption ( [Formula: see text] ) was significantly decreased in patients compared with healthy controls. In conclusion, this exploratory study demonstrates significantly reduced exercise capacity in NSCLC pre-cachexia despite maintenance of muscle mass and unaltered indices of UPS activation. The absence of muscular NF-κB-dependent inflammatory signaling supports the notion that transition of systemic to local inflammation is required to initiate UPS-dependent muscle wasting characteristic for (experimental) cachexia.

Exercise and cancer survivorship

The association between exercise and cancer incidence has long been established. Increasingly research is considering the role of exercise in the oncology setting. This article summarizes the current evidence for exercise promotion in cancer survivors and guidelines for exercise participation in this population.

Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: a systematic review

CONTEXT

The role of exercise intervention for patients with Non-small cell lung cancer (NSCLC) has not been systematically reviewed to date.

OBJECTIVE

To identify, evaluate and synthesize the evidence examining (1) the effect of exercise intervention on exercise capacity, health related quality of life (HRQoL), physical activity levels, cancer symptoms and mortality for patients with NSCLC; and (2) the safety and feasibility of exercise intervention for a population with NSCLC.

DATA SOURCES

A systematic review of articles using the electronic databases MEDLINE (1950-2010), CINAHL (1982-2010), EMBASE (1980-2010), TRIP (1997-2010), Science Direct (1994-2010), PubMed (1949-2010), Cochrane Library (2010), Expanded Academic ASAP (1994-2010), Meditext Informit (1995-2010), PEDRO (1999-2010) and DARE (2010). Additional studies were identified by manually cross referencing all full text reports and personal files were searched. No publication date restrictions were imposed. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials (RCTs), case-control studies and case series assessing exercise intervention to improve exercise capacity, HRQoL, level of daily physical activity, cancer symptoms or mortality of patients with NSCLC were included. Only articles available in English and published in a peer reviewed journal were included.

DATA EXTRACTION

A data collection form was developed by one reviewer and data extracted. Data extraction was cross checked by a second reviewer. RESULTS AND DATA SYNTHESIS: 16 studies on 13 unique patient groups totalling 675 patients with NSCLC met the inclusion criteria. The majority of studies were case series (n=9) and two RCTs were included. Studies exercising participants pre-operatively reported improvements in exercise capacity but no change in HRQoL immediately post exercise intervention. Studies exercising participants post-treatment (surgery, chemotherapy or radiotherapy) demonstrated improvements in exercise capacity but conflicting results with respect to the impact on HRQoL immediately post exercise intervention. Heterogeneity among studies was observed and a meta-analysis was deemed inappropriate. PRISMA guidelines were followed in reporting this systematic review.

CONCLUSION

Exercise intervention for patients with NSCLC is safe before and after cancer treatment. Interventions pre-operatively or post-cancer treatment are associated with positive benefits on exercise capacity, symptoms and some domains of HRQoL. The majority of studies are small case series therefore results should be viewed with caution until larger RCTs are completed. Further research is required to establish the effect of exercise during and after cancer treatment and in the advanced stage of disease, the optimum type of exercise training and the optimum setting for delivery.

Effects of aerobic training on oxidative status in postsurgical non-small cell lung cancer patients: a pilot study

BACKGROUND

Oxidative stress is postulated to contribute to the initiation, promotion, and progression of non-small cell lung cancer (NSCLC). We investigated the effects of supervised, moderate-intensity aerobic training on urinary markers of oxidative status in patients with postsurgical NSCLC.

PATIENTS AND METHODS

Sixteen patients with histologically confirmed stage I-IIIB NSCLC were recruited. Exercise training consisted of aerobic cycle ergometry sessions at 60 to ≥70% of baseline peak workload 20-45 min·d(-1), 3 d·wk(-1)for 14 weeks. Oxidative status was assessed via four urinary F(2)-isoprostanes isomers: iPF (2-alpha)-III, 2,3-dinor-iPF(2 alpha)-III, iPF (2-alpha)-VI, and 8,12-iso-iPF(2 alpha)-VI using liquid chromatography with tandem mass spectrometry detection. Peak oxygen consumption (VO2peak) was assessed using a maximal, incremental, cardiopulmonary exercise test with expired gas analysis.

RESULTS

A composite index of all four F2-isoprostanes isomers increased from baseline to post-intervention by 32% (p = 0.08). Concerning individual isomers, iPF (2-alpha)-III increased by 0.09 (+55%; p = .010), iPF (2-alpha)-VI by 0.81 (+29%; p = 0.04), and 8,12-iso-iPF(2 alpha)-VI by 0.59 (+28%; p = 0.07) from baseline to postintervention. There was no change in 2,3-dinor-iPF(2 alpha)-III levels. VO2peak increased 1.1 mL·kg·(-1) min(-1) (p = 0.14) and peak workload increased 10 Watts (p < .001). Change in VO2peak was not associated with change in markers of oxidative status.

CONCLUSIONS

Aerobic training was associated with significant increases in urinary measures of oxidative status in postsurgical NSCLC. The clinical implications of these findings are currently unknown. Further studies are required to elucidate the complex relationship between aerobic training, oxidative stress, tumor biology, and response to cytotoxic agents in mouse and human models of cancer.

Changes in functional performance measures in adults undergoing chemoradiation for primary malignant glioma: a feasibility study

PURPOSE

To investigate the feasibility of longitudinal assessment of functional performance measures in newly diagnosed postsurgical malignant glioma patients.

METHODS

Patients with histologically confirmed, clinically stable, postsurgical, and previously untreated high-grade glioma (HGG) or low-grade glioma (LGG) were studied. Using a prospective design, all participants performed a cardiopulmonary exercise test with expired gas analysis to assess cardiorespiratory function (VO(2peak)) immediately following surgical resection (mean, 10 days). Additional functional outcomes were skeletal muscle cross-sectional area (CSA) via magnetic resonance imaging, isokinetic muscle strength (isokinetic dynamometry), and body composition (air displacement plethysmography). Quality of life (QOL) was assessed by the Functional Assessment of Cancer Therapy-Brain scale. All study assessments were repeated at 6 and 24 weeks following surgery.

RESULTS

Thirty-five patients (HGG, n = 25; LGG, n = 10) completed baseline assessments. Of these, 20 HGG (80%) and nine LGG (90%) and 15 HGG (60%) and nine LGG (90%) patients completed study assessments at 6 weeks and 24 weeks, respectively. Intention-to-treat analyses indicated several significant time-by-group interactions, with favorable improvements in functional and QOL endpoints from baseline to 24 weeks in the LGG cohort and unfavorable changes in the HGG cohort. Per-protocol analyses including participants assessed at all three study timepoints indicated significant improvements in VO(2peak) and fatigue from baseline to 24 weeks in the HGG cohort; peak workload, body composition, and muscle strength improved from baseline to 6 weeks (all p-values < .05).

CONCLUSIONS

Longitudinal quantitative functional assessments are safe and feasible among select patients undergoing chemoradiation for primary malignant glioma. Large prospective studies investigating the clinical importance of these measures appear warranted.